We need to talk about the future of the NHS

Another general election campaign, another failure to address the big issues threatening the long term future of the NHS. For the all the muster and bluster of the last five weeks, debate on the NHS has failed, once again, to focus on the two issues that matter most – the rapidly rising gap between funding and long term demand and the growing NHS workforce crisis.

It’s not as if we haven’t been warned. Report after report over the last two years – from the Office of Budget Responsibility (OBR) to the House of Lords Committee on NHS Sustainability – have shown that we face an explosion of demand for healthcare services as our population ages, treatments improve and expectations rise.

The reports have all clearly demonstrated that the amount of our national wealth or Gross Domestic Product (GDP) we devote to the NHS will have to rise substantially if we want to keep the same range and quality of NHS services. The OBR, for example, projects that spending on health would have to rise from 7.3% of GDP in 2016/17 to 12.6% in 2066/67 to keep up with demand.

Answers to really difficult questions

This requires answers to some really difficult questions including what taxes we will raise to pay for this increase; or should we move to a French top up system in which we have a basic level of taxpayer funded care with anything else funded through social insurance; or should we start charging for certain parts of the service?

Most of us working in the NHS want to preserve its core principle – universally available treatment, free at the point of use, based on clinical need, not ability to pay. But we face difficult choices if this principle is to survive to 2066.

Most of us working in the NHS want to preserve its core principle – universally available treatment, free at the point of use, based on clinical need, not ability to pay. But we face difficult choices if this principle is to survive to 2066.

Chris Hopson chief executive

Given this context, the general election debate on NHS funding risks looking like an irrelevant sideshow. We’ve only been talking about the five years immediately in front of us, ignoring the longer term problem. And, welcome though any commitment to extra NHS funding is, all the main parties’ NHS funding proposals don’t get us anywhere near where we need to be.

The existing plan, pre-election, was that the NHS budget in 2022/23 would rise from this year’s £124 billion to £128 billion. We’d actually need an NHS budget of £141 billion in 2022/23 just to keep up with the NHS cost and demand increase we’re already forecasting. We’d need a budget of £155 billion to match what the OBR thinks is needed.

And the manifesto proposals? According to the Nuffield Trust, the Conservative and Liberals Democrat plans would raise the NHS budget in 2022/23 to £132 billion. Labour’s plans would raise it to £135 billion. Crucially, all three would involve spending less of our national wealth on the NHS just at the point when we need to spend more.

Air of unreality

There’s a similar air of unreality around the proposals on workforce. Frontline NHS leaders are increasingly clear that the NHS is now in a workforce crisis. Workforce gaps are rapidly opening up, driven by Brexit uncertainty, seven years of NHS pay restraint and rapidly growing burdens on staff that are making NHS jobs look increasingly unattractive. Service quality is at risk and frontline NHS leaders are increasingly caught between the rock of running services that may be unsafe and the hard place of trying to close or consolidate them.

The general election campaign has offered few realistic answers to these issues. Instead, we’ve had a fantasy Dutch auction in which the political parties have vied to promise the highest number of new NHS posts that, in reality, their proposed NHS budget can’t afford and NHS frontline leaders won’t be able to fill because of insufficient recruits.

It’s perhaps understandable that our politicians are nervous of difficult long term debates that involve hard truths for the public - look what happened during the campaign to the debate on funding social care. It feels like the NHS and social care are in danger of becoming the third rail of British politics – the big looming problems that no one will grasp for fear of instant electrocution.

We need someone to lead this much needed national debate on the long term future of the NHS.

Chris Hopson chief executive

But we need someone to lead this much needed national debate on the long term future of the NHS. And if the politicians won’t or can’t, those of us who want the key principles of the NHS to survive will have to step into their place.

What we can’t do is pretend, for another five years, that we can close the current gap between rapidly rising demand and insufficient funding growth by asking the frontline NHS to do the impossible and then castigate them when they inevitably fall short.